Franklinsmiles.com

Franklin Smiles Patient Registration 1214 Murfreesboro Rd, Suite 210 Franklin, TN 37064 615-794-2444 info@franklinsmiles.com Welcome! We are dedicated to the concept that all people have the opportunity to retain their teeth throughout their lifetime with optimum health, function, comfort and esthetics. We realize the importance of your smile and are committed to offering the best that dentistry has to offer-providing quality restorative dentistry with special emphasis on cosmetics. Thanks for coming! NT INFORMATION Last Name: ______________________________ First Name: _________________________________ Gender: _ ___M ____F Marital Status: ____Married ____Single ____Other irth: _______________________ Social Security #: _______________________ Email Address: _____________________________________________________ dress: ________________________________________ City: ________________ ST____ Zip: ________ Home Phone: ___________________ Business Phone: _________________ Cell Phone: _________________ How did you hear about our office? _______________________________________________________________ DENTAL INSURANCE (Medical insurance does not apply-provide dental insurance information only) Name of Employer: __________________________________ Name of Subscriber: ____________________________ Subscriber ID: ___________________________ ber Date of Birth: _________________________ Group #: _________________________ Insurance Company: ___________________________ ng Address for Dental Claims: ____________________________________ City: _______________________ ST: _________ Zip: __________ Phone: _______________________________ IMPORTANT! PLEASE READ: Franklin Smiles and Dr. J. A. Reynolds are not contracted providers with any insurance company. Please contact your carrier to determine how this will affect your benefits. Any unpaid balances will be your responsibility. MEDICAL HISTORY (circle all that apply) Allergies
Other: ____________________________________________________
DRUG ALLERGIES or Other Allergies (circle all that apply) Amoxicilli
Other: ________________________________________________________________
ARE YOU TAKING ANY MEDICATIONS? ___Yes ____No (If yes, list below)
___________________________________________________________________________________________ _________ __________________________________________________________________________________ _________ __________________________________________________________________________________ _________ __________________________________________________________________________________
OR WOMEN ONLY
Are you pregnant? ____Yes ____No (If yes, when are you due? _______________)
Are you taking birth control pills? _____Yes _____No
DENTAL HISTORY
Date of Last Cleaning/Exam _____________________
Name of previous dentist: _______________________________
Have you ever had orthodontics, periodontal surgery, or other major medical treatment? If yes, explain: _________ _______________________________________________________________________________
ld you like Dr. Reynolds to do for you? List any items you wish to discuss with Dr. Reynolds:
__________________________________________________________________________________________________________
____________________________________________________________________________________________
Please ind icate yes or no (Y/N) to the following:
___ Do you have any areas where food impacts around your teeth?
___ Do your gums tend to bleed easily, feel irritated or tender?
___ Are your teeth sensitive to hot, cold, pressure or sweets?
___ Do you have pain in your head, neck, shoulder, or upper back?
___ Do yo u have popping, clicking, or other noises in your jaw joints?
___ Are yo u aware of grinding or clenching your teeth? ___ Have y ou ever had any negative reactions to a dental injection or nitrous oxide? ___ Are yo u anxious or nervous about dental treatment?
Is the appearance of your smile important to you? Rate the importance on a scale of 1 to 10: ________
(1=Not concerned at all; 10=VERY concerned)
CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION By signing this form I am consenting to the use and disclosure of protected health information to carry out treatment, payment activities, and healthcare operations. I understand that the information above is necessary de dental care in a safe and efficient manner. The answers provided above are correct and complete. ng this form, you agree to inform this office of any changes in your medical history. Your signature indicate s you understand that Dr. Reynolds is HIPPA compliant and all precautions will be taken to protect ACCOUNT INFORMATION By signing this form, I understand the financial responsibility for dental services provided in this office for myself and/or my dependents is mine. Insurance is filed as a courtesy and I understand I will pay any estimated portions and any portions not paid by insurance. I further understand payment is due at time of service. DENTAL INSURANCE By signing this form, I agree to provide current and correct insurance information to Dr. Reynolds. I agree to pay the estimated patient portion at the time of service. I understand that any balance NOT paid by insurance is my full responsibility. I understand Dr. Reynolds is not a contracted provider with any insurance company and it is my responsibility to research my policy for limitations regarding out-of-network providers. *I understand if the insurance company has not provided payment within 60 days of the submission date, the claim will be closed and the remaining balance becomes my full responsibility.

PARENT OR GUARDIAN If patient is a child, please read & sign below: I understand that the information above is necessary to provide my child with dental care in a safe and efficient manner. To my knowledge answers are correct and complete. Realizing that the use of anesthetic agents embodies certain risks, I will inform this office of any changes in my child’s medical history. I further authorize and consent that Doctor Reynolds and/or his assigned may utilize diagnostic aids deemed appropriate and perform all forms of treatment, medication, and therapy deemed necessary in connection with the dental care of patient until written notice is given discontinuing this permission.

N Scale Weathering: Concepts and Techniques N SCALE WEATHERING: CONCEPTS & TECHNIQUES Concepts: The weathering of N Scale locos and rolling stock requires some unique thinking in order to achieve realistic results. There are plenty advantages of weathering in N Scale and I will try to demonstrate how we can use these to improve the overall appearance of N scale locos and rolling stock to

10/7/08 FOR IMMEDIATE RELEASE Exelon Power Switches On Westinghouse Lighting System for Savings. Philadelphia, PA — Who does the electric company turn to when it wants to save energy? Exelon Corporation is one of the nation’s largest energy companies, generating and distributing electricity to millions of customers in Illinois and Pennsylvania. When the company slated a reno